Consent for Telehealth


Telehealth includes the practice of psychological health care delivery, counselling, therapy, consultation, treatment, referral to resources, and education by connecting with individuals using interactive video and audio communication platforms. Room to Breathe Counselling has opted to utilize “” as its mechanism for providing online counselling. Counselling over the telephone is also an option if online counselling is not possible for the client. The use of other technology, such as the use of e-mail and text, can be useful for scheduling appointments or sharing files for education, or activities, that can be completed outside of sessions. The term “telehealth” will be used when referring to any or all electronic platforms mentioned above.

Because online counselling and telephone counselling are relatively new practices, there is not a lot of research regarding their effectiveness, therefore the use of online and telephone counselling will be reserved for use in situations where face-to-face therapy is not possible or is impractical.

As I am registered only with the Manitoba College of Social Workers, this means I am only able to practice within Manitoba and with individuals living in Manitoba, even if technology makes it possible to work with individuals outside the province.

By consenting to Telehealth, I am confirming I understand and/or agree to the statements below:

  • I am a permanent resident of Manitoba, or an individual currently living in Manitoba for the purposes of attending school or work.
  • I agree to receiving file transfers from Room to Breathe Counselling, as needed, to the e-mail address provided to my counsellor on the Consent for Therapy form. I understand that my counsellor will not include anything in the e-mail that will compromise my personal health information, but that there will always be a risk of a third party intercepting the message. I will not be asked to return completed forms to my counsellor over e-mail because of this risk.
  • I agree to receiving texts from my counsellor for the purposes of scheduling or modifying appointments or as a means of checking on my safety should other methods fail.


The laws that protect the confidentiality of individuals’ personal health information also apply to telehealth services. As such, I understand that the information disclosed by me during the course of therapy is generally confidential. However, there are mandatory exceptions to confidentiality as described in the Consent for Therapy Form.

By consenting to Telehealth, I am confirming I understand and/or agree to the statements below:

  • I am aware that my counsellor may be required by law to break confidentiality in situations where she has reason to believe that my safety or safety of another person is at risk, or if required by court order.
  • My counsellor will never record or share sessions held by telehealth and I agree never to record or share our sessions, or parts of sessions, with a third party.
  • I am aware that in order to confirm my identity and to ensure another individual is not attempting to gain access to my personal health information, my counsellor may ask me questions such as my date of birth and home address.


By consenting to Telehealth, I am confirming I understand and/or agree to the statements below:

  • I am aware that Room to Breathe Counselling will not be responsible for any of my costs associated with participating in telehealth.
  • I will be responsible for making a payment for my session even if I find I am distracted, have difficulty maintaining privacy, or lose the connection with my counsellor due to weak Wi-Fi or poor cellular connection.
  • Fees associated with telehealth appointments are payable by credit card or e-transfer once the invoice is received from Room to Breathe Counselling.


By consenting to Telehealth, I am confirming I understand and/or agree to the statements below:

  • I have the right to withdraw my consent at any time.
  • I understand that I may benefit from telehealth services but that results cannot be guaranteed or assured.
  • I understand that if my counsellor believes I would be better served by another form of psychotherapeutic service (e.g. in-person crisis services) I may be referred to another resource.
  • I understand that scheduling is based on my counsellor’s normal office hours.

In order to successfully participate in telehealth services, as well as to minimize associated risks, I agree to the following:

  • I will have a reliable source of Wi-Fi or cellular connection.
  • I will ensure that my device’s battery is sufficiently charged or that it is plugged in during the session.
  • I will make every effort to ensure that I have adequate privacy during the telehealth session.
  • I will take all reasonable steps to limit distractions during the telehealth session, including putting my phone on “do not disturb”, turning notifications off on apps or programs that may be running in the background, letting others know that I am occupied for the duration of the session as to limit interruptions, etc.
  • In the event that I am disconnected from my counsellor, I am aware that my counsellor will attempt to re-establish the same connection up to 3 times. If these attempts are not successful, I agree to answer my phone so that my counsellor and I can make alternate arrangements and/or so that my counsellor can further assess my situation. If I do not answer my phone and my counsellor has reason to believe that I or someone else is at risk, I am aware that my counsellor may call my emergency contact person listed on my Consent for Therapy Form or appropriate authorities to ensure my wellbeing or the wellbeing of another individual.
  • Should we be unable to re-establish a video connection and attempts to reach me by telephone have been unsuccessful and my counsellor is not able to reach me by text and I feel I need continued emotional support, I am aware I can access the following services:
    • Klinic Crisis Lines at 204-786-8686
    • Mobile Crisis Unit at 204-940-1781
    • I can go to the Crisis Response Centre at 817 Bannatyne Ave in Winnipeg
Consent for Telehealth
Consent *
Telehealth preference (please check only one)